solving a problem

The other night I wandered into the ICU just to look around. Our vascular surgeons seem to be going through another AAA phase, with record numbers hitting the door in the last few weeks, and I wanted to see how things were going in the ICU.

I found one of the junior residents, Joe, just getting into a difficult discussion with a patient’s family. He was an old man, with a lot of problems, and this time around they had all caught up with him at once. He was in respiratory failure, on a ventilator; his kidneys were failing, and he had already had one round of dialysis; his blood was filled with a raging infection, which didn’t seem fazed by all the antibiotics he was receiving; his liver was starting to look bad; and the monitors were showing more and more abnormal beats, indicating that his heart didn’t have far to go either. The resident explained to me, behind the nurses’ station, that he had received a very frustrated signout on this patient: “He’s in multi-system organ failure. There is nothing we can do for him surgically, or medically either. He shouldn’t even be in the surgical ICU, since he hasn’t had surgery recently. Just make the hospitalists take him, or something. It’s hopeless.”

Joe was not one to take a passive approach. He decided that since no one else had managed to get very far in talking with the family, and since he didn’t want to be the one running multiple hopeless codes on this old man through the night, until finally he didn’t respond to ACLS protocol any more, he would tackle the job of getting DNR status from the family.

I was frankly curious. Much as I hate to think about it, in four months I’ll be the one left over night with four or five ICUs full of patients, and I’m sure it won’t be long before I run into this problem. I wanted to hear what he said. It helps that Joe is about six foot four, with a quarterback’s build. I don’t think I’ll ever make as impressive and authoritative a figure as he does. He told the son and daughter quite bluntly that their father was in bad shape. He explained how all his organs were failing at once, and went through the list of heroic interventions which were necessary just to maintain the status quo. Then he got down to it. “Your father is not going to survive this. I’m sorry to say this, but he is going to die, soon. The question is, how much more do you want him to go through before he dies? Right now, if his heart stops, we’ll do everything we can, giving him drugs and pushing on his chest. It might work for a little while, but it’s not going to reverse what’s going on here.” Within an hour, they signed DNR papers, and the old man died that night.

I believe that what Joe did was good. He helped the son and daughter understand what was happening, probably better than anyone had before. He helped them come to some kind of terms with their father’s impending death, before it happened. He decreased the patient’s suffering, by not forcing him to go through futile codes, and letting him go a little more peacefully. He helped the surgical team, by solving a problem for them.

I’m sure that within a year, I will do the same thing. But right now, I can’t picture it. I tried to imagine the words in my mind, but somehow, despite how much my understanding of “end-of-life issues” has changed in the last eight months, I still can’t make those pessimistic words come out. I still try to think of what might happen well, how things might turn around. I tried to imagine a discussion about “do not intubate” status, which is an oxymoron and a disaster (how can you code somebody, or even try to do pressor support, if you can’t maintain an airway? it’s useless). Some recent tragedies have demonstrated that DNI status simply ties the doctors’ hands. The patient should be either DNR, if everyone is ready to let go, or full code, if it seems like a survivable illness. But whenever I try to put words to that, I find myself arguing for full code. Maybe things will get better; we shouldn’t give up yet.

I think Joe had it on his list for the night: “Check CBC on Mrs. Adams. Serial abdominal exams on Mr. Jones. DNR status, likely death, of Mr. Smith. . . ” Maybe after I run a few hopeless ICU codes, it will be easier to go hunting for DNR status, just another item on a list.

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3 Responses to “solving a problem”

Alice,
I hope it will ever be just another number on a list for you. I believe that you will come to appreciate the value of a dignified passing rather than one useless code after another. It didn’t take me very long in the NICU to recognize the baby who had absolutely no chance — borderline is something entirely different and deserves that full code at least once.

I had been out of nursing school less than a year and was working in a small-town hospital which just happened to have a level III NICU. One night, we got a call from the delivery room. A baby had been born at 22 weeks gestation (way before viability 30 years ago) and the OB was bringing him to us. Usually the nurses did, but this time the doc brought him up. He was tiny — barely a pound. His skin was gelatinous and he wasn’t even gasping. He did have a heartbeat, though, so he came to us for ‘comfort care’. When the covering pediatrician arrived about 15 minutes after the birth, the baby’s father asked her why we weren’t doing everything for his baby that we were doing for the 2 lb 26 week baby in the next bed.

I knew this pediatrician. She was a lovely woman and a good doctor, but so soft-hearted that she simply could not bring herself to tell this father the truth – that his baby was dying and nothing short of a miracle could possibly change that.

She said, “We could do what we are doing for that baby if you wish.” and paused.

I quickly added, “Yes. If you want, we could do those things, but in the end it won’t change anything. That baby is much more mature than your baby. If we do all those thing, your baby might live a few hours or possibly even a few days. The things we would have to do would be very uncomfortable for your baby and in the end it will make no difference. Would you like to have the baby baptized?”

So we baptized the baby. His father held him while he died – and it was not the last time I cried at work.

You will learn to recognize when the situation is hopeless and it is kinder to help the family to say goodbye. You might even be able to get away with shedding a tear – something your male colleague isn’t permitted.

Both of our stories above are quite interesting. This is something I have thought about alot as I have progressed through medical school. I honestly think that we try too hard to keep people alive…and to be honest, by the time the heroic efforts are complete, I don’t think you would call the body that is left “alive”.

As a Christian, I have thought about whether I had any obligation to keep my patients alive like that. From what I have read in the Bible, it always seemed like Jesus was more concerned about our eternal life than our current finite life. Heck, Jesus raised Lazarus from the grave (which was great), but in the end Lazarus died again. Death is inevitable in this world; of course as physicians, we want to do the best for our patients, but sometimes I feel like the best is letting them go.